Pages

Wednesday, December 2, 2015

“All the
doctors say I need to give up smoking,” he says, “though science isn’t done by
consensus, and I’ve come across some really interesting blog posts. Now, I’m
not a doctor, but it’s pretty clear to me that there’s real uncertainty on the
question of smoking causing lung cancer or heart disease or lung disease or any
of the other things smoking is supposedly “bad” for. Smoking is
clearly good for the lungs because it helps you cough up all that junk.”

At this point he pauses to cough up some brown phlegm into a tissue.

“Anyway. I
do believe the doctors, and they say I should give up smoking completely.
Though, obviously, smoking will be a big part of my lifestyle for a long time
to come. I mean, if I stopped smoking immediately, it would cause me economic
ruin.

“Eh?” I
ask. “How’s that. You won’t be paying for cigarettes any more, and you’ll get
healthier.”

“Ah,
details.” He says. “Trust me. I have shares in tobacco. I’ll never be able to
retire if I don’t prop up the entire industry.”

“You won’t
be able to retire if you keep smoking. You’ll be dead,” I can’t stop myself
from replying.

“Only two-thirds of smokers die young, and medical care is getting better and better, and, because
I’ve had private health insurance for a long time, and shares in private health
insurance, I’m much better off economically if I keep smoking, and you don’t
look too hard at the numbers.”

“Don’t look
too hard at the numbers?”

“So, because I absolutely believe what the doctors say…”

“That you
should give up?”

“… Yes,
that I should give up, I’m going to take their advice and cut down.”

“Cut down?”

“Yes. I’m
setting a target for a 5% reduction in my cigarette consumption based on 2005
levels.”

“How much
were you smoking in 2005?”

“Oh, about 50
cigarettes per day. It was only 35 before that, but it went up.”

I examined
his face for signs of a joke, but he looked very serious.

“What? So you’re
cutting down to 47 cigarettes a day?”

“Yes, I am.
But I’m currently only smoking 35 cigarettes a day. Well. 40. But I’m allowed
to count it as 35 because of a complex cigarette accounting rule where I can
carry over previous cigarette reductions into this year.”

He managed
to keep a straight face.

“But that
means you can actually increase your smoking.”

“No. Well,
yes. But it means I’ve hit my target.”

“But you’re
increasing your smoking.”

“Well,
frankly, that’s one of the oddest and strangest and I’ve got to say ...
desperate arguments I’ve ever heard.”

There was
still no sign that he wasn’t taking this seriously.

“So. I’ve
hit my target,” he repeated with emphasis.

“But what
about stopping smoking altogether?” I ask, a little confused now.

“I aim to
cut future smoking by a 26% based on 2005 levels, by 2030. Which puts me way
ahead in the middle of the pack of my smoking cessation group.”

“What? But
your group are cutting smoking by 40% and upwards.”

“Yes, as I
said I’m way ahead of them.”

“What? 26%
compared to 40%”

“Yes. Because
I’m measuring it per capita.”

“Eh? You’re
not making any sense!” I was getting a bit frustrated now.

“Exactly. I’m
hitting targets all over the place.”

“But your
targets are rubbish. The doctors say you need to stop smoking.”

“Yes, and I’m
doing everything the doctors say with my ambitious target of reducing my smoking
by 26%, much much more than everyone else in my smoking group.”

I looked at
him. He really seemed to believe this. He looked back at me, still straight-faced.

“So how
will you achieve this tiny reduction?” I venture nervously.

“Well. I’ll
achieve this ambitious reduction with a policy. You know how those so-called
experts that I believe say we should tax cigarettes so it becomes expensive to
buy them?”

“Yes.
Definitely. There’s good evidence that it works.”

“Well. One
man’s evidence is anther man’s anecdote…”

“No, it’s
not!” I shouted

“… and that
policy would lead to me buying fewer cigarettes, and lead to my economic ruin.
No, I have a much better policy. The government will pay me for every cigarette
I don’t smoke.”

“…. What?...”

“I’ll put
in a bid in a reverse auction along with all the other smokers. And If I’m one
of the winners, then I get money for each cigarette I don’t smoke.”

“That’s a
crazy policy,” I say. “That’ll never work.”

“Oh, that’s what they all say,” he tells me. “But I know it will.”

“How do you know that?”

He waved
his hands in the air and just said “Woooooooooooo! See. It’ll work.”

He wasn’t
laughing.

“And if you
don’t win the auction?”

“I might
cut down anyway.”

“What? Well
what use is that?” I ask

“It’ll make
me stop smoking. Isn’t that what you want?”

“But… but..
what a complete waste of money!”

“Not at
all. I get the money. Do you see? I get the money. How can that be a waste? You’re
not very bright are you?”

“And what
if you get the money and don’t give up?”

“Oh, that’s
the really clever part. Listen to this. A man – or a woman, it doesn’t matter –
comes round to my house and says ‘Don’t do that again!’”

“What? Is
that it?”

“Yes. That’s
a strong robust compliance mechanism.”

“No, it isn’t.”

“I’m glad
you agree with me.”

“But I didn’t.”

“Thank you.”

I took a long slow deep breath and counted to 10.

“So. Let me
get this right. You’ve been told to stop smoking, but instead you can increase
your smoking and get money for doing it.”

“No. I hit
my targets. You’re concentrating too much on that increasing bit. I hit my
targets. And I get money. It’s a perfect system, you see.”

“And what
do your doctors say about it?”

“Oh, I don’t
believe a word they say. I found this on Wikipedia”

He looked
straight at me. Was that a smile playing around the corner of his mouth? Was
that a knowing wink I saw? No. It wasn’t.

Thursday, June 18, 2015

Well, Imogen didn't get an answer from the PM to her last letter.. She's phoned his office (yes, really) but heard nothing. She's still really angry and upset about the way we are treating children in asylum detention, so she's written another letter to the PM.

Perhaps we need to listen to children more.

Please feel free to share widely.

To the Hon Tony Abbott PM,
I am usually proud to be an Australian. Proud to live in a country where we have freedom of speech,
proud to live in a country where we won’t be killed for speaking out against the government. But
recently, I have been becoming less and less proud of my home. Less proud of the government that
is supposed to represent our nation’s views. Less proud of a country with ‘boundless plains to share’.
A country that doesn’t seem to be able to help anyone whose life is in serious danger.
Because right now, despite how much you insist that you ‘stopped the boats’, despite the
government’s little tale that you are ‘helping’ these people, despite your continued reference to
these people as statistics, men, women, and children are dying out at sea as they try to reach what
they believe is a safe refuge, here in Australia. Little do they know, the few people who actually
make it here will be locked up in the equivalent of jails, men, women and children alike.
Their crime, you might ask? Trying to find a place where they won’t be murdered for having their
own views, for being a woman, or for having a different religion to their government. Seeking a
country where their children can have a proper life, free of fear of death when they wake up each
day. Is that so evil of them that we have to lock them up in prisons, where they are abused by
guards, where 5 year olds self-harm? A place that most Australians would not think fit for their pet
dog?

I am sure, that in their position, you would have done the same. Because would you stay in a

country where your family could be brutally murdered every day? Where people are whipped, or
worse, for speaking out against their government? Is it such a crazy dream to live in a place where
you can properly appreciate life?

Recently, I heard a story about a 5 month old baby, born in Australia, who was sent back to Nauru.
Yes, we are talking about the place where 5 year olds have tried to commit suicide, guards treat
people abominably, and human beings sleep in tents not fit for a dog. Just think about the situation
from the point of someone other than an Australian who lives a sheltered little life. This baby is
going to grow up in Nauru. It is going to be the only world it knows. Instead of having a normal,
happy childhood, like I am having, and you have had, she will have a broken childhood. Many
experts have said that Nauru is not safe for infants, and certainly not suitable.

I believe that Australia needs to open its eyes and see the horrific things that are being done right
now, because in the future we will look back on it and be ashamed of our inhumane, cruel and just
plain evil things that we have done.

I will conclude with the second verse of our proud country’s national anthem, because it seems as
though our government has forgotten the words.

Beneath our radiant Southern CrossWe’ll toil with hearts and hands;To make this Commonwealth of oursRenowned of all the lands;For those who’ve come across the seasWe’ve boundless plains to share;With courage let us all combineTo Advance Australia Fair.In joyful strains then let us sing,Advance Australia Fair.

Monday, April 13, 2015

My oldest daughter and I were in the car together when we heard Julian Burnside talking on the radio about children so desperate that they had attempted suicide while in asylum detention. It was heartbreaking.

I discovered today that my daughter wrote to the Prime Minister about it.

This is what she wrote.

To the Hon Tony Abbott MP,

On the 31st of March, 2015, I was listening to Radio
National on my way down to school with my dad. It was a Tuesday, and a normal
day. On the radio, a lawyer called Julian Burnside was talking, and he caught
my attention. He was talking about the effects of offshore detention on
children, my age and younger. Right now, 133 children are being held in
immigration detention facilities within Australia, and 107 are held in
detention on Nauru. He was telling a story of a young girl and her family. This
girl was 11 years old. To put this into perspective, she is 2 years younger
than me. She had come over from Iran to
seek asylum in Australia, and had then been sent to one of our detention
centres, with the rest of her family, for 18 months. She was horribly
mistreated here, abused by guards and under-nourished. They came to live in Australia,
because she was in such a bad way that she needed psychiatric help. Here, the
11 year old child hung herself with a bedsheet. They took her to hospital. At
hospital, no one was allowed to visit her because ‘visiting hours on Nauru were
from 9am-5pm’.

If an 11 year old child is trying to KILL herself, because of what us
Australians are doing, what does that mean? Because of Australians, because we
lock people away who just need safety and help, because of our law, children
are trying to kill themselves.

There is another girl right now, 5 years old, who is in Darwin. She
has been told that she has to go back to Nauru, back to the place where she was
treated how no child should be treated. Back to her nightmare. This child is
also suicidal. This 5 YEAR OLD CHILD is trying to kill herself. And why?
Because of what our law has done to her.

Julian Burnside went on to remind us that seeking asylum is not
illegal. Nor are these people criminals. You and your government claim that
by keeping the ‘criminals’ in offshore detention that you are protecting
Australia. Do you think that a 5 year old child, who wants to kill herself, is
likely to be more of a danger to Australia or to herself? Do you think that
sending her back to Nauru, to ‘protect Australia’, is worth her life?

I can’t get my head around the fact that while I live my life, while I
get driven to school by my dad, while I enjoy normal Tuesdays, children younger
than me are killing themselves. And there’s nothing I can do. But you can. You
have the power to save people’s lives. You can do more than I can.

It is your government that is doing this to human beings. It is your
law that makes children kill themselves. It is our narrowed and stubborn minds
that mean innocent people die. It is Australia that needs to save lives.

Of
course, your
tax subsidises this to the
tune of over $6bn (yes, billion). Governments see Private Health Insurance (PHI) as
being an important part of the health system mix in Australia. One of the
budget KPIs is to maintain the number of people covered by private health
insurance hospital cover. As well as rebates of 30% of the premium, the tax
system penalises high income earners who don't take out health insurance. And
Peter Dutton, the former health minister, can
even be seen spruiking health insurance.

What do the co-payment and Private Health Insurance mean for health policy?

Combining a liking for co-payments and PHI, this is my
prediction for the worst case direction of future health policy under the
current government:

Watch as Private Health Insurers
and their members argue that clearly co-payments to see the GP should be
covered by Private Health Insurance {Evidence
– PHI already lobbying government on this}

Bow to this pressure – it’s only
what the public want. Allow Private Health Insurance to cover General Practice.
{Evidence – Government already allowing
trials of this in Brisbane}

Private Health Insurers compete
for customers by offering favourable access to GPs, and paying GPs more than
they get from Medicare. {Evidence – this is
the basis of the trial in Brisbane. Admin fee paid to practice, 24 hour access
guarantee for members}

GPs opt out of Medicare system,
as they get better paid and easier access to referral networks {Evidence – compare specialist care in public
and private systems}

IPA, Private Health Insurance Companies
and their customers argue they pay PHI so should be able to opt out of Medicare
altogether. {Evidence – this would be the
small government libertarian position}

Medicare gets progressively
underfunded and seen as a second rate safety net rather than a universal health
system.{Evidence – it’s already referred to as a safety net}

A look at
Private Health Insurance through a lens of who actually needs good health care
the most shows why this progression needs to be resisted.

Who has Private Health Insurance?

Nationally,
about 47% of Australians hold hospital insurance coverage. It has gone up
slightly each year since 2010, and is fairly constant across the states (with
more in the ACT and fewer in the NT).

Looking
at insurance coverage by age, we see fewer being covered in their late 20s, and
a big drop in coverage in the elderly.

Who doesn't have Private Health Insurance?

It's a statement of the obvious to say that those who don't have health insurance are those who can't afford the premiums. And that would certainly be true.

So, as people are more advantaged, they are more likely to have PHI (orange boxes increasing) and less likely to have a concession card (blue boxes decreasing).

This is all very well, but it is a well know fact that the more disadavntged you are, then the more health problems you have. (I am writing another post all about this, but you can see the stats before I write).

Health Costs

Private
Health contributes less than 8% of the total
health spend (less
than half the amount contributed by individuals themselves in out of pocket
costs).

What does Health Insurance buy - "For
our members"?

Private
health insurance have a difficult time selling you something in a universal
health system. If the health system is going to give you high quality, timely
care when you need it regardless of your ability to pay, what can they offer?
This, I suspect, is one reason why the government want to turn Medicare into a
safety net, rather than a universal health system - to generate a product to
sell for profit. Private health insurance need to be able to convince you
you're getting something you wouldn't otherwise get. That's why it's always
"For our members." Here are the options:

Access to Allied Health
This is another major one. Seeing a physiotherapist, or an exercise
physiologist, or a dentist or a psychologist can be difficult in the
public system, especially if it’s not part of a hospital admission.
Medicare will only cover a limited number of these in particular
circumstances.

Higher quality health care
You will receive high quality health care pretty much anywhere you go in
Australia. That is, yes, you will always find people who are unhappy about
their care, but health care is complex, and things will go wrong. However,
public or private systems have no monopoly on things going wrong. And
often, when things go wrong in the private system, people are moved to the
public system for it to be corrected.
It's also worth remembering that in hospitals, it is the public system who
is usually involved in education and training of future health
professionals, which can make for high quality (and can also look
inefficient on a balance sheet!)

Friendlier staff
No health professional goes into their job wanting to be rude. It's stress
and burnout that make this happen, which comes about from expecting too
much of staff while giving them too few resources to do it. That's why
staff ratios might be good and cases less complicated. It's easy to be
friendly then!

Nicer rooms
This is often the case in the private system (though not necessarily if
the public system charges your insurer for their services). I don't see
any reason for not having nice rooms in public hospitals. It just seems to
be that we are happy to see out insurance premiums pay for it, but not our
tax. Which seems sort of odd to me.

Remember
that having private health insurance doesn’t solve all your health care
problems. Most policies are subject to exclusions – are you covered for having
a baby? Mental illness? You are with Medicare! There are also significant
patient copayments, which are often unclear when the policy is taken out or
when you start treatment.

We can
see that private health insurance companies, and perhaps politicians who want
PHI to take the pressure off the public system, and perhaps health professionals
who might be paid more privately than in the public system all have an interest
in ensuring that the publically funded system has long waits, limits to the
professionals you can see and happens in less pleasant environments. Often this
won’t be explicit – it may even be subconscious – but results in thinking of
the public system as a safety net, not a universal system.

Summary - why private health doesn't improve population health

We've seen that Private Health Insurance is mostly bought by those who can afford it, who, by a happy coincidence are also those who are likely to be the healthiest. Clearly, there's not too much profit to be made by paying out on insurance for people with more conditions, or needing more complex case management.

So when we pay over $6bn in tax rebates on private health insurance premiums, that's money going from our tax to those who are already well off enough to afford PHI premiums. But not to those who have most illness or the most need of it. That money can't help Close the Gap, for example, when it has no way of reaching the 85% of Aboriginal and Torres Strait Islander people in non-remote areas without Private Health Insurance.

And when we allow Private Health insurance premiums to rise by 6.2% each year, but freeze Medicare revenues, that's paying more each year for the health care of those who need it least, while ensuring a cut in real terms for those who rely on Medicare, and ensuring they will have to contribute out of their own pockets. General Practices will gradually have to move away from communities that can't pay to those that can.

When we allow Private Health to sell a product that allows us to jump a queue on the basis of our ability to pay, rather than our clinical need, then that moves those better off and less likely to have high health care needs to the front of the queue. This already happens in the hospital system, and will happen in General Practice if we allow it. Freezing Medicare rebates makes this more likely, as the only source of revenue to keep practices viable is patients.

And eventually, if Medicare is a safety net unused by those who are better off (where more political power lies) then it will be allowed to gradually wither as it serves only those without money, power or influence.